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Excellus BCBS · 2 months ago

Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)

Rochester, NY

Full-time

Onsite

Mid, Senior Level

$65K/yr - $118K/yr

3+ years exp

Excellus BCBS is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to ensure accurate coding and DRG assignment by reviewing medical records. The role involves auditing inpatient claims, adhering to coding guidelines, and providing mentorship to new hires while maintaining high standards of integrity and compliance.

Health CareHealth InsuranceNon Profit

Work & Life Balance

Responsibilities

Analyzes and audits acute inpatient claims

Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities

Draws on advanced ICD-10 coding expertise

Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates

Establishes national and best practice benchmarks and measures performance against benchmarks

Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform

Manages case volumes and review/audit schedules, prioritizing case load as assigned by Management

Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs

Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures

Regular and reliable attendance is expected and required

Performs other functions as assigned by management

Performs complex audits or projects with minimal direction or oversight

Acts as an expert in reviewing medical coding and medical record review with ability to oversee complex assignments, challenging customers, and highly visible issues

Supports leadership in projects related to divisional/departmental strategies and initiatives

Participates and represents in audits, payment methodologies, contractual agreements, with cross functional teams or with business partners as needed

Serves as a mentor to new hires

Demonstrates ability to participate and represent department on interna/external committees

Provides expertise in developing data criteria for audits

Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members around methods of continuous quality improvement

Serves as an expert and resource for escalations and works directly with Payment Integrity staff to resolve issues and escalation problems

Provides backup support for Management as necessary

Qualification

ICD-10 codingMS-DRG knowledgeAPR-DRG knowledgeClaims auditingCoding certificationAnalytical skillsProblem-solving skillsProject managementSoftware proficiencyLeadership skillsCommunication skills

Required

Associate or bachelor's degree in health information management (RHIA or RHIT) or a Nursing Degree

Three (3) years' experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting

Three (3) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology

Coding Certification is to be maintained as a condition of employment of one of the following: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC

Intermediate analytical and problem-solving skills; as well as keeps abreast of latest trends related to business analysis

Intermediate knowledge of PC, software, auditing tools and claims processing systems

Five (5) years' experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting

Five (5) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology

Demonstrated ability across multiple skills, products, processes, and systems with the Division

Demonstrated ability to lead initiatives with occasional guidance and assistance from management and/or others

Advanced analytical, problem solving, and judgement skills

Advanced knowledge of PC, software, auditing tools and claims processing systems

Eight (8) years' experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting

Eight (8) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology

Demonstrated leadership skills

Demonstrated ability as a subject matter expert or consultant to other departments

Demonstrated ability to work independently and assumes lead role in key business initiatives

Expert proficiency in analytical skills, auditing skillset and ability to manage complex assignments, challenging situations, and highly visible issues

Demonstrated expert proficiency in project management and presentation skills

Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer

Ability to travel across the Health Plan service region for meetings and/or trainings as needed

Benefits

Participation in group health and/or dental insurance

Retirement plan

Wellness program

Paid time away from work

Paid holidays

Company

Excellus BCBS

Glassdoor4.0

Excellus BlueCross BlueShield, a nonprofit independent licensee of the BlueCross BlueShield Association, is part of a family of companies that finances and delivers vital health care services to about 1.5 million people across upstate New York.

Founded in 1932

Rochester, New York, USA

5001-10000 employees